Nicole

SRS History

Hi I am Nicole. I had SRS in Thailand with Dr. Sanguan in October 2001. He performed the first stage of the surgery on October 2nd. In the pre surgical visit, he felt there would be enough tissue available to give me at least five inches depth without additional skin grafts. I told him I wished to avoid additional skin grafts as I had seen examples of his skin grafts and did not care for the amount of scarring which accompanied them.

When I awoke following the first stage surgery, I found out I had been in OR approximately six hours. I also found out Dr. Sanguan had encountered some bleeding problems he did not anticipate, and that he could not give me depth beyond four inches without additional skin grafts. Again, I reiterated my desire to avoid additional skin grafts. At this time I began to feel I was being made the victim of a bait and switch routine.

A few days later Dr. Sanguan took me back to OR to change the dressing and discovered the surgical site was not healing as he would have liked, so he decided to delay the second stage of surgery a couple of days. The second stage surgery was performed approximately one week after the first stage. I spent four hours on the operating table this time.

Five days after the second stage, all the packing was removed. At this time it was found that the whole surgical site had become infected. Antibiotics were not given right away pending culturing of the infection which took a couple of more days. Antibiotics were only started after it was determined I had contracted a staph infection. Also during this time the grafted tissue began to die, and I was left with no tissue surrounding the vaginal opening up to and surrounding the urethra.

I had been carrying on correspondence with my roommate via the Internet and the phone. She is also post op TS and began to become very concerned about my health and safety. So much so she asked the U.S. embassy to ask the hospital what was happening. The upshot was that I was left too ill to travel and without a completed SRS. I needed to either let Dr. Sanguan perform a third operation and graft more tissue, or go to Bangkok and let Dr. Preecha finish the surgery.

Because I was so ill, too ill to really travel, I opted to let Dr. Sanguan perform a third operation to cover the surgical site with skin. He took two full thickness grafts from my flanks in the area between my pelvic bone and lower rib. Each scar is nearly five inches long. The third operation required another 6 hours on the operating table, and another 10 days recovery time in the hospital.

After the packing had come out following the third procedure, dilation began. However, my vaginal opening was so small and tight I could not use the set of vaginal dilators supplied by the hospital. Instead candles of appropriate size had to be found. Even today, two and a half months after surgery, I still cannot use normal dilators.

I left the hospital and Thailand on October 30th and flew home, having been in the hospital 29 days.

Post Operative Complications

When I arrived home I was twenty pounds under weight. I could barely dilate and urination was difficult. I was also still carrying an infection. If fact, I was so ill I wound up in a local hospital the very next weekend. While in the hospital they could not even examine the inside of my vagina with a speculum due to the small size of it's opening. They administered IV antibiotics and started me on oral antibiotics. It was hoped that alleviating the infection and reducing the swelling would allow me to urinate and dilate.

The infection began to clear, but it was becoming increasingly difficult to urinate or dilate. It seemed that instead of expanding, my vaginal opening was closing down. Just before Thanksgiving I went back to the urology clinic. There they took me into a procedure room where they dilated my urethra open and sent me home with a box of catheter tubes and instructions to dilate my urethra open twice daily.

As you can imagine, dilating one's urethra open is a painful proposition. It didn't take long for the scar tissue to occlude the urethral opening and make self dilation impossible, At this time the vaginal opening had become so restricted from scar tissue I was forced to quit dilation all together.

By December I was having extreme difficulty voiding urine at all. By luck I found a referral to an OB GYN who also does pelvic surgery. He specializes in women whose vaginas have been damaged as a result of radiation treatments for ovarian cancer. He had never treated a TS woman, but my collapsing vagina and urinary problems were similar to problems we handled. The first visit he dilated open my urethra and tried to open my vagina. He succeeded in opening the urethra, but the vagina far too painful for him to examine.

He immediately started me on antibiotics and scheduled more appointments. In the weeks just before Christmas it became impossible to find my urethral opening without difficulty and a foul smell began emanating from the vagina. The doctor worked very hard to dilate open my urethra, and inserted at permanent catheter tube. He also concluded that immediate surgery was necessary. So, the Friday before Christmas, not even two months after returning home from Thailand, I was back in surgery.

The Corrective Surgery

(Taken Dec. 2001 2 ½ months after SRS)

On the Friday before Christmas, my OB GYN performed a meatomy on my in order to open up my urethra. While he had me under anesthesia , he also forced my vagina open and found the skin inside beginning to decay.

In the pre op picture it is possible to see the general arrangement of the clitoris, urethra opening (which has already been catheterized), and the vaginal opening. It is important to note how very close the urethra and vaginal opening are, as well as the small size of the vaginal opening. It is also possible to see the scar tissue, which, in this picture is the brighter red, and extends from just below the clitoris, down around the urethra, and the top one third to one half of the vaginal opening. It is this scar tissue which occluded the urethra making it impossible to urinate, and keeps the vaginal opening from expanding. The scar tissue means the vaginal opening is tear shaped at best and can only expand downward towards the anus.

The post meatomy picture clearing shows how the urethra was opened and held back with stitches. After one month the urethra remains open and urination is normal. It is also possible to clearing see the scar tissue, which, in this picture, appears as a lighter pink. After the doctor opened the vagina, he inserted a soft stent made from a condom filled with gauze and sewed it into place. This kept the opening from closing during the healing process.

Post Meatomy Progress

Ten days after the meatomy was performed I returned to the doctor's office. At this time the catheter was removed and I began to urinate freely. For the first time since leaving Thailand, I felt I could urinate freely. The stream is strong and straight. Subsequent testing has disclosed I can fully empty my bladder. Furthermore, after nearly a month it appears the scar tissue is no longer encroaching on the urethral opening.

I was also given a pessary to be worn inside my vagina. This is what my doctor describes as passive dilation, a procedure often used for woman whose vaginas have collapsed. In addition to passive dilation, I started active dilation again, returning to my candles. At first, I could only use the smallest candle like I had done in Thailand, but it did not take long for the vaginal opening to begin stretching. Currently, I start with a dilator that is approximately 20 mm and work my way up to a dilator that is 23 mm. The smallest dilator sent home from Thailand was 25 mm. I currently wear a pessary which is 20 mm all day and all night which keeps the vaginal opening from closing off. My doctor wishes to move me up to the next size pessary which is 24 mm and hopes to get me there soon. I will need t wear that pessary for a year to keep the vaginal opening from collapsing again. To that end he's taken the largest dilators sent home from Thailand (which I'll never use anyway) and is having them milled down to sizes which will allow me to expand to the point of using the 25 mm dilator.

Below is a copy of the operative report

By Mikio A. Nihira, M.D. GYN

DATE OF OPERATION: 12/21/2001

39-year-old status post sexual reassignment surgery in Thailand in October of 2001. That procedure was complicated by a slough of the scrotal graft for the neo-vagina. Approximately two weeks after the primary procedure she had a secondary procedure and then a tertiary procedure in which the grafts were augmented with more skin graft taken from her lateral flanks. Despite these attempts she has had progressive stenosis of her vagina and her urethra since that time. She presented in early December to the Parkland ER. She was evaluated by the plastic surgeons, as well as the urologists. She was found to have a distal urethral sphincter in the urology laboratory under fluoroscopy. She was dilated to a 22-French and was discharged with 14-French straight catheters to continue intermittent catheterization at home. Despite these measures she presented to my office in the second week of December complaining of recurrent stenosis of the urethra and the vagina. We were going to temporize her condition as she was still able to urinate. We started her on topical estrogen cream. We resumed her systemic estrogen.

She then returned to my office on 12/18/01 complaining of very great difficulty voiding. Examination in the office revealed a very stenotic urethral meatus. It would barely permit passage of a 18-gauge angiocath. After local anesthesia was applied, we then dilated her so that we could place a 14-French Foley catheter and made preparations for urgent dilation in the operating room.

PREOPERATIVE DIAGNOSIS:

Urethral vaginal stenosis after sexual reassignment surgery.

POSTOPERATIVE DIAGNOSIS:

Same.

PROCEDURE:

1) Urethral dilation.

2) Cystoscopy.

3) External urethral meatomy.

4) Vaginal dilation.

COMPLICATIONS: None.

FINDINGS:

1) Markedly stenotic external urethral meatus that was compromised primarily by scar tissue.

2) Cystoscopic findings revealed a normal membranous and prostatic urethra. No evidence of a bladder injury or foreign body.

3) At the end of the procedure her urethra permitted passage of a 30-French dilator easily and her vagina was dilated to approximately 3 centimeter in width and approximately 6-8 centimeter in depth.

INTRAVENOUS FLUIDS:

Was about 800 cc of crystalloid.

ESTIMATED BLOOD LOSS:

Less than 50 cc.

PROCEDURE:

After general endotracheal anesthesia had been establish, the patient was placed in the dorsosupine lithotomy position where she was prepped and sterilely draped.

Starting out with the #2 Hegar dilators, we gradually dilated the urethra till it would permit a #10 Hegar dilator, which is approximately 30-French. We then placed the rigid 17-French cystoscope transurethrally and performed urethral and systematic cystoscopic examination. The findings were normal with no evidence of any false tracks noted. We then directed our attention to the external urethral meatus. Given that there was a great deal of scar tissue externally we decided to perform a meatomy. 1-centimeter incisions were created at 12, 5, and 7 o'clock positions. 3-0 braided absorbable suture was then used to create interrupted subepithelial stitches to evert the urethral epithelium. A 16-French Foley catheter was placed.

Attention was brought to the vagina. Gentle blunt dissection was used to extend the length of the vagina. At the top of the vagina a palpable fold was noted. Gentle blunt dissection was able to open this fold. Direct examination revealed denuded epithelium at the top of the vagina. There was no active bleeding noted. Digital rectal exam was then used to confirm that we had not perforated the rectum with this dilation. The vagina was then biopsied at the approximately 5 o'clock position, as well as the external introitus for estrogen receptor testing. These sites were hemostatic. The vagina was then occluded with a vaginal stent made by a rolled up 4X4 gauze insheathed in a condom that was tied off at the end. Two sutures were placed at the 5 and 7 o'clock position to secure the stent to the vaginal introitus.

The lap and instrument counts were correct times 2. The distal urethral opening was infiltrated with approximately 7 cc of % Marcaine. The procedure was then terminated.

Mikio Nihira, MD, MPH

Assistant Professor Department of Obstetrics and Gynecology

5323 Harry Hines Blvd

Dallas, TX 75390-9032

Dr. Sanguan Kunaporn's Comments

Dear DaleLynn and Nicole

Thank you for your information about Nicole's post op complication and very glad to know that at least now she is recovered from urination problem. I had no any contact from Nicole after she left Thailand until you mailed me last week.

I am so very regret about Nicole's SRS result. If she was in Thailand, I would never let her down because of the complication. It is my duty and responsibility to help her in any way as much as I can do like I did for a few patients of mine who had complication from SRS before.

The complication of Nicole started from the failure of scrotum skin graft that caused by infection even we always give antibiotic to the patient after surgery. It is quite rare in our series, After we use the new technique of VAC dressing two years ago with delay skin graft a week after the SRS, we had only two cases of graft failure, one is the British patient and the other is Nicole. The surgery itself went so smooth, there is no injury to Urethra, bladder or rectum. As we knew, when Nicole lost the graft because of Staph infection, she was so sad and depressed and even panic and wanted to go back to USA without letting me fix the problem. I explained to her that even she went back to USA after the graft damage, the surgeon in USA also would do like I did for her, the re-skin graft, to try to give a chance for the raw wound around that area to heal as much as possible. If not, it would heal like a worse scar and might complicate more than she had it in the last two months. She finally decided to stay longer to let me do that. It is our strict policy to help in every way to let our patient have the best result and in case of complication, to fix the problem by charging no any extra money. I assumed that Nicole realized it. This policy rarely exists in other clinic.

Fortunately, the new skin grafts survive and she, in some level, was better and ready to go back home. If she was in Phuket longer and I encountered the complications that she had, I would also do the same thing like her doctors had done. Because I knew that there was no injury to the Urethra or the bladder from SRS procedure, the most common problem of difficulty of Urination is the stenosis of the opening of the Urethra from the scar formation and leading to the bladder infection. I ever corrected this problem for some patients who had SRS done from other surgeons before. As I thought, when the patients had some complication, some of them were not trust to go back to see her previous surgeon, so they preferred to meet other one. Also in Nicole case, she might have no confidence in mine anymore and she was also not in Thailand, so I had no chance to help her correct that complication.

For the stenosis of vagina or even the surrounding labia, I would like her to calm down and wait for at least 6 months from SRS. The time is the best solution now. After 6 months, the scar will be soften enough to let the surgeon do the revision vaginoplasty and labiaplasty. This is also common for every related plastic and reconstructive cases, when the surgeon had to correct something, they need to wait at least 6 months before next surgery. Nicole then has to decide that how much she really need for the vagina depth. If she satisfy with the shallow vagina, no problem with urination, have orgasm by clitoris stimulation, do not expect full penis penetration, she may not need the revision surgery.

But if she really needs the deep, functional vagina, at least 5-6 inches, wide enough for full penis penetration, she must need secondary vaginaoplasty using combination between skin graft for the vulva and opening of the vagina and Rectosigmoid colon for the rest of the vagina canal. However, this procedure is so invasive and more risk of complication than the standard SRS. If she think that she cannot tolerate in case of the complication occur, she should not consider it.

I can perceive that she lose the confidence in mine, however, I just can tell her that I am always willing to help her reconstruct the unsuccessful surgery whenever she is ready without any cost of surgery. I realize that every patients of mine has to save all the money for this important, one time chance, operation and most of all are not rich; so the best thing that I can do for them is to help them get to their goal by insure them the exact cost of surgery they have to pay.

I have no excuse about the failure of Nicole case, just want her

to know that I am always ready to help her if she need.

Regards

Sanguan Kunaporn

kunaporn@phuket.ksc.co.th

Nicole's Second Corrective Surgery:

Scar Removal and Rotational Flap

(7 months post op - May 2002)

Presurgical Background

In February 2002, I began to experience problems with my vaginal opening as a result of internal scaring left from my original SRS in October 2001. The vaginal opening would not expand large enough to accept any dilator larger than the ones I had specially made. These dilators were smaller than the smallest one sent home from Thailand, which I could never use. The vaginal opening would not expand because of a band of scar tissue about an inch wide, just behind the

vaginal opening. I could feel it with the dilators or with my finger. Every time a dilator, stent, or pessary was passed through it, it would tear and bleed. Consequently it would heal over, rescar, and become tighter than was before.

By March 2002 (five months post op) dilation of any kind had become impossible, and the vaginal opening had closed up so tight it was no longer possible to douche. In addition, the constriction of the vaginal opening was distorting the urethral opening, making urination difficult again. It had

become apparent that a surgical procedure was necessary to correct the problems. The enclosed pictures show the condition of the vaginal opening and the surgical procedure used to remove the scar tissue and reline the vagina.

The first picture (Nicole preop) taken in early April shows the condition of the vaginal opening before the second corrective surgery. One can see how tightly the vaginal opening is closed and how small the urethral opening is. One can also see a sore formed of underlying granulated tissue which has extruded through the thin layer of skin around the vagina. A similar sore existed on the left side but is not visible. The sore of the left subsided prior to corrective surgery, while the one on the right was removed in an office procedure.

Rotational Flap Surgery

Rotating a flap of skin from the inner thigh into the vagina was determined to be a suitable procedure for correcting the scarring remaining from the initial SRS. The surgery was performed in May 2002, seven months after initial SRS and five months after the myotomy performed on the urethra. In the second picture (scar removal) taken in the operating room during the corrective surgery, one can see how the scar tissue has been removed from the left side of the vaginal opening and down the left inside of the vagina. To correct the urinary difficulties, the urethra was dilated open and catheterized. It stayed catheterized for the next 48 hours. One can also see the pre surgical markings for the flap of skin to be rotated into the vagina. Initially the surgeons wanted to do both sides of the vagina in the same operation, but chose to do only the left side during this procedure because after scanning the area with ultrasound, it was found that the left side had a more steady blood supply. It was hoped that by freeing the left side, the caliber of the vaginal opening would be sufficient and not need additional surgery.

The third picture (rotational flap) shows the flap of skin and muscle freed from the left inner thigh and ready to be rotated into place to cover the scar tissue on the left inside of the vagina and the left side of the vaginal opening. What is so different about this procedure is that unlike a skin graft where skin is harvested from one place on the body and grafted onto another,

the skin is freed from near where it is to be used and rotated into place. The rotated skin retains it's original blood supply, unlike skin that is harvested, and remains more supple and with less chance of shrinkage or sloughing.

The final picture (completed flap) shows the flap of skin after it has been sewn in place. As a matter of orientation the clitoris is slightly left of the top center of the picture and the urethra has been catheterized. One can see the suture lines which run up the left inner thigh to about the top of the vulva, and outwards from the vaginal opening 3 to 5 inches. One can see immediate improvement in the appearance of the vagina with a dramatic reduction in the amount of visible scar tissue.

Post Surgical Outcomes

I spent about 48 hours in the hospital following this procedure. The drain inside the vagina and the soft stent sewn in place in the vaginal opening were removed after the first 24 hours. The catheter was removed after 36 hours and I began to urinate on my own, although the stream angled off to the left. By the time I was released I could move about own my own, albeit slowly. I spent another 48 hours at home resting in bed or sitting in a comfortable chair. After that I was able to move about freely and drive. The stitches dissolved or popped loose and the swelling subsided over the next couple of weeks. During that time I have follow-up visits with first the assisting surgeon, then with the head surgeon. During these visits no post operative complications were observed.

Three weeks after the procedure I tried dilation again. It was very hard to insert anything into the vaginal opening. While it was apparent that the left side was more flexible than before, the right side was even tighter than and would not allow me to insert any dilator. The stream of urination still remained angled off to the left. In a follow up visit one month from the surgical date, I expressed my concerns to the head surgeon. After an examination he determined the scar tissue on the right inside of my vagina was restricting the overall caliber of the vagina opening and that the urethra needed to be moved more to the center. Thus planning began for another operation to remove more scar tissue and correct the remaining problems.